6.08 Gas Pain and Constipation

Presentation

Excruciating, bloating, sharp, crampy, migratory abdominal pain may double
the patient over, but last only a few seconds and is relieved by
bowel movement and passing flatus. It may be related to loud bowel
sounds (borborygmi) but not to position, eating, or other causes, and
is not accompanied by other symptoms, such as nausea, vomiting,
diarrhea, urinary urgency, et cetera. Rarely are patients awakened
with nocturnal symptoms. The physical examination is also benign,
with no tenderness, masses, organomegaly, or other abnormalities, and the patient does not appear ill between the episodes of abdominl pain. Bowel sounds may become loud during each episode of cramps.

What to do:

Take a thorough history and try to determine the time of onset of symptoms and whether their severity is increasing or decreasing. Ask if there was a similar episode in the past. Perform a complete physical examination, including rectal and/or pelvic examination, and a repeat abdominal examination after an interval.

If the presentation is not clear, consider using diagnostic tests like urinalysis (to help rule out renal colic or urinary tract infection); differential white blood cell count (a clue to infection or inflammation); abdominal x rays (to show free peritoneal air or bowel obstruction); ultrasonography (pyloric stenosis, malrotation and intussusception in children, appendicitis and gallbladder disorders).

If constipation is part of the problem, disimpact the rectum, if
necessary, and try one enema in the ED.

Instruct the patient to try relieving symptoms with ambulation,
and local heat, and to return to the ED or see his personal
physician if symptoms do not resolve over the next 12-24 hours.
Suggest bulk in the form of bran or Metamucil for prophylaxis.

If the problem is chronic or recurrent, or associated with alter
nating constipation and diarrhea, suspect irritable colon
inflammatory bowel disease or diverticulitis.

What not to do:

Do not discharge the patient without one or two hours of
observation, and two abdominal examinations. Many abdominal
catastrophes may appear improved for short periods, only to worsen
in an hour or two.

Discussion

While a patient may swallow excessive air in response to anxiety, an increased rate of "empty" swallowing may also accompany a number of gastrointestinal abnormalities including hiatal hernia and chronic cholecystitis. Heartburn increases salivation and therefore the frequency of swallowing. In addition to air swallowing. intraluminal gas-producing bacteria provide the other major mechanism for causing excess intestinal gas. Some patients may be helped by advising them to reduce or eliminate their intake of foods that contain non-absorbable carbohydrates such as beans, broccoli, cauliflower and cabbage. Alternatively, they can be instructed to take Beano food enzyme tablets with these healthful foods.

Colic attacks usually start when an infant is 7 to 10 days old and increase in frequency for the next one to two months. they do not just happen suddenly one night when the infant is six or eight weeks old. In that situation, look for some other acute problem such as corneal abrasion, incarcerated hernia or digital hair tourniquet in an infant who is irritable or feeding poorly with no previous problems. Constipation is one of the most common causes of pediatric abdominal pain. After a digital rectal examination, a glycerin suppository in infants or a single cleansing enema in children may provide rapid symptomatic relief.